The following Schedule
of Benefits is designed as a quick reference. For complete
provisions of the Plan’s benefits, refer to the following sections:
Health Care Management, Medical Expense Benefit and Plan
Exclusions. A complete listing of participating providers can
be obtained from the Human Resources Department. Limitations are combined
maximums for services and supplies rendered by Preferred and Non-Preferred
Providers.
MEDICAL BENEFITS:
|
Maximum Benefit per Covered Person while covered by this Plan
for:
|
| |
Medical
|
$ 1,000,000
|
| |
|
|
| |
|
|
| |
Chemical Dependency
|
25,000
|
|
Maximum Benefit per Covered Person per Calendar Year for:
|
| |
Mental and Nervous Disorders
|
Inpatient/30 days per calendar
year
|
| |
|
Outpatient/25 visits per
calendar year
|
| |
Chemical Dependency Inpatient
&/or Outpatient Hospital
|
|
| |
Inpatient Services
|
$ 10,000
|
| |
Chemical Dependency
Outpatient Services
|
2,000
|
| |
(Included in the Inpatient
and/or Outpatient limit of $10,000)
|
|
| |
Extended Care Facility/Treatment
and Confinement
|
30 days per calendar year
|
| |
Chiropractic Care
|
$ 300
|
| |
Home Health Care
|
100 visits per Calendar
Year
|
| |
Preventive Care
|
$ 300
|
|
|
|
|
|
Calendar Year Deductible:
|
| |
Individual Deductible
|
|
| |
Family Deductible (Aggregate)
|
|
| |
|
|
Coinsurance Expense Limit Per Calendar Year
|
| |
Individual
|
|
| |
|
|
Additional Deductibles
|
|
| |
Hospital Admission NOT Pre-Authorized
|
|
| |
Outpatient Surgery NOT Pre-Authorized *
|
|
| |
*Outpatient Surgeries where
the Surgeon’s charges are $401 or more require Pre-Authorization.
Refer to the section entitled Health Care Management for
more details.
|
Limitation per Occurrence
|
|
| |
Hospital Inpatient/Outpatient
Surgery Covered Expenses NOT Pre-Authorized/
Network Provider
|
| |
|
80%
|
| |
|
80%
|
| |
|
|
| |
Hospital Inpatient/Outpatient
Surgery Covered Expenses NOT Pre-Authorized/
Non-Network Provider
|
| |
|
60%
|
| |
|
0%
|
The following are
Covered Dental Services. Refer to the section entitled Dental
Provisions, Dental Benefits, for details regarding the services
covered, exclusions, limitations and other provisions of the Dental
Benefit.
|
ALL PROVIDERS
|
|
CLASS I
|
80%
|
| |
Limitation: Subject to maximum annual benefit per person
|
|
|
CLASS II
|
80%
|
| |
Limitation: Subject to deductible and
maximum annual benefit per person.
|
|
|
CLASS II
|
80%
|
| |
Limitation: Subject to deductible and
maximum annual benefit per person.)
|
|
|
CLASS IV
|
50%
|
| |
Limitation: Subject to
deductible and maximum lifetime benefit per person.)
|
|
ALL CLASSES
CLASSES I, II,
III
CLASS IV
(To be effective
July 1, 1998)
|
ALL PROVIDERS
|
|
Individual Calendar Year Deductible:
|
$25
|
|
Examination / Maximum Benefit:
|
$40
|
| |
Limitation: One exam during any 18 consecutive
months.
|
|
|
Conventional Lenses / Maximum Benefit:
|
|
| |
Single Vision
|
$40
|
| |
Bi-focal
|
$50
|
| |
Tri-focal
|
$60
|
| |
Lenticular
|
$120
|
| |
|
|
| |
|
$200
|
| |
|
$100
|
| |
Limitation: One pair during any 18 consecutive
months.
|
|
|
Frames / Maximum Benefit:
|
$40
|
| |
Limitation: One pair during any 18 consecutive
months.
|
|
|
Refer to the section entitled Vision Expense Benefit for
complete details.
|
|
For the purpose
of determining the Coinsurance and Out-of-Pocket Expense Limit, Covered
Expenses are divided into the following three categories:
CATEGORY 1:
This category applies
to such Covered Expenses made by all Preferred Providers. For
Employees who reside or work outside the Preferred Provider service
area (50 Miles or more from the nearest Preferred Provider), Covered
Expenses for Non-Preferred Provider services and supplies shall be Category
1 expenses.
CATEGORY 2:
This category applies
to such Covered Expenses made by Providers that are Non-Preferred Providers
if:
1.
Such expenses are made by pathologists, radiologists, or anesthesiologists
in connection with a covered Inpatient Preferred Hospital Confinement
or a covered Outpatient procedure performed in a Preferred Hospital.
2.
Such expenses are necessitated by an Emergency condition (as
defined in the Plan), and then only to the following extent: (a) in
the case of Emergency Outpatient treatment, such expenses incurred within
twenty-four (24) hours of the accident; and (b) in the case of an Inpatient
Hospital Confinement, such expenses up to the day the Covered Person
can reasonably be expected to safely transfer to a Preferred Provider.
3.
Such expenses are for care, treatment, services, or supplies
that are not rendered by any Preferred Provider.
4.
Such expenses are incurred while traveling outside of the Preferred
Provider area (50 miles or more from the nearest Preferred Provider).
CATEGORY
3:
This category applies
to such Covered Expenses made by all other Non-Preferred Providers.
Note: If the
Covered Person elects to use Category 3, the Coinsurance payable by
the Covered Person shall NOT apply to the Out-of-Pocket Expense Limit.
Out-of-Pocket
Expense Limit Per Calendar Year:
| |
Individual
|
$ 1,000
|
| |
Family (Aggregate)
|
2,000
|
Refer to the
section entitled Medical Expense Benefit, Out-of-Pocket Expense
Limit for a listing of charges not applicable to the Out-of-Pocket
Expense Limit.
The Plan pays the
percentage listed on the following pages for Covered Expenses incurred
by a Covered Person during a Calendar Year after the Individual or Family
Deductible has been satisfied and until the Individual or Family Out-of-Pocket
Expense Limit has been reached. Thereafter, the Plan pays 100% of incurred
Covered Expenses for the remainder of the Calendar Year, or until the
Maximum Benefit has been reached. Refer to the section entitled Medical
Expense Benefit, Out-of-Pocket Expense Limit for a listing of
charges not applicable to the 100% Coinsurance.
|
PLAN A
Benefit Description
|
PPO Provider Category
1
|
(see Page 7) Category
2
|
Non-PPO Provider Category
3
|
|
INPATIENT HOSPITAL
|
90%*
|
80%
|
70%**
|
| |
* Benefits for Inpatient
Hospital/Network/Not Pre-authorized will be subject to a separate
and additional $300 Deductible and 80% Coinsurance payment per
unapproved admission.
|
| |
** Benefits for Inpatient
Hospital/ Non-Network/Not Pre-authorized will be subject to a
separate and additional $300 Deductible and 60% Coinsurance payment
per unapproved admission.
|
| |
|
|
|
|
OUTPATIENT SURGERY
|
90%*
|
80%
|
70%**
|
| |
* Benefits for Outpatient
Surgery/Network/Not Pre-authorized will be subject to a separate
and additional $300 Deductible and 80% Coinsurance payment per
unapproved surgical procedure.
|
| |
** Benefits for Outpatient
Surgery/Non-Network/Not Pre-authorized will be subject to a separate
and additional $300 Deductible and 60% Coinsurance payment per
unapproved surgical procedure.
|
| |
|
|
|
|
ER SERVICES
|
100% after $100 Co-pay* Deductible
Waived
|
100% after $100 Co-pay* Deductible
Waived
|
100% after $100 Co-pay* Deductible
Waived
|
| |
*The $100 Co-payment is
waived if Covered Person is admitted to the Hospital; coverage
reverts to Hospital Inpatient as noted above.
|
| |
|
|
|
|
URGENT CARE
|
90% Subject to Deductible*
|
90% Subject to Deductible*
|
90% Subject to Deductible*
|
| |
*No Co-payment required.
|
| |
|
|
|
|
SUPPLEMENTAL ACCIDENT
|
100% Ded. Waived up to $500.*
|
100% Ded. Waived up to $500.*
|
100% Ded. Waived up to $500.*
|
| |
*Limitation: Maximum
Benefit is $500 per accident; coverage then reverts to Plan Benefits.
|
| |
|
|
|
|
PRE-ADMISSION TESTING
|
90%
|
80%
|
70%
|
|
PHYSICIANS’ SERVICES
|
90%
|
80%
|
70%
|
| |
Assistant Surgeon’s Covered
Expenses not to exceed 20% of the primary Physician’s Covered
Expenses.
|
| |
|
|
|
|
SECOND SURGICAL OPINION
|
|
|
|
|
|
100% Ded. Waived
|
100% Ded. Waived
|
70% Ded. Waived
|
|
|
100% Ded. Waived
|
100% Ded. Waived
|
70% Ded. Waived
|
|
OUTPATIENT DIAGNOSTIC
|
|
|
|
|
|
90%
|
80%
|
70%
|
| |
|
|
|
|
|
90%
|
80%
|
70%
|
| |
Limitation: Up to 30
days for treatment and Confinement per Calendar Year.
|
| |
|
|
|
|
|
90%
|
80%
|
70%
|
| |
|
|
|
|
|
90%
|
80%
|
70%
|
| |
Limitation: Maximum Benefit
per family unit for family bereavement counseling is $200.
|
| |
|
|
|
|
|
90%
|
80%
|
70%
|
| |
Limitation: Maximum Benefit
per Calendar Year not to exceed 100 days rental; Maximum Benefit
per Calendar Year for rental of Apnea Monitor (except if used
for infants), T.E.N.S. Unit, or equipment designed to assist bones
to heal faster is limited to $200 each.
|
| |
|
|
|
|
|
100% to $300 Ded. Waived*
|
Denied
|
Denied
|
| |
*Limitation: Up to $300
per Calendar Year benefit.
|
| |
|
|
|
|
|
90%*
|
90%*
|
70%*
|
| |
*Inpatient services subject
to maximum 30 days per calendar year; Outpatient services subject
to maximum 25 visits per calendar year.
|
| |
|
|
|
|
|
|
|
|
|
|
90%*
|
90%*
|
70%*
|
| |
*Limitation: $10,000
per Covered Person, per Calendar Year for Inpatient and Outpatient
Hospital.
|
| |
|
|
|
|
|
50%*
|
50%*
|
50%*
|
| |
*Limitation: $2,000 per
Covered Person, per Calendar Year (included in the Inpatient and/or
Outpatient limit of $10,000).
|
| |
|
|
|
|
|
90%
|
80%
|
70%
|
| |
|
|
|
|
|
90%
|
80%
|
70%
|
| |
|
|
|
|
|
N/A
|
100%*
|
N/A
|
| |
*Maximum Benefit: $25
per treatment; maximum of 26 treatments per Calendar Year.
|
| |
|
|
|
|
|
N/A
|
80%
|
N/A
|
| |
|
|
|
|
|
N/A
|
90% Ded. Waived
|
N/A
|
| |
|
|
|
|
|
90%
|
80%
|
70%
|
| |
|
|
|
|
|
N/A*
|
N/A*
|
N/A*
|
| |
*100% after Prescription
Drug Co-payment: $5 generic/$15 brand name. Generic will be dispensed
unless specified “Dispense as Written.” Maintenance drugs will
be dispensed through a mail order program.
|
| |
|
|
|
|
|
|
|
|
For the Purpose
of determining the Coinsurance and Out-of-Pocket Expense Limit, Covered
Expenses are divided into the following three (3) categories:
CATEGORY 1:
This category applies
to such Covered Expenses made by all EPO Hospitals. For Employees who
reside or work outside the EPO service area (50 miles or more from the
nearest Preferred Provider), Covered Expenses for Non-Preferred Provider
services and supplies shall be Category 1 expenses.
CATEGORY 2:
This category applies
to such Covered Expenses made by all other Exclusive Providers and such
Covered Expenses made by Providers that are not Exclusive Providers
if:
1.
Such expenses are made by pathologists, radiologists, or anesthesiologists
in connection with a covered Inpatient Exclusive Provider Hospital Confinement
or a covered Outpatient procedure performed in an Exclusive Provider
Hospital.
2.
Such Expenses are necessitated by an Emergency condition (as
defined in the Plan), and then only to the following extent: (a) in
the case of Emergency Outpatient treatment, such expenses are incurred
within twenty-four (24) hours of the accident; and (b) in the case of
an Inpatient Hospital Confinement, such expenses up to the day the Covered
Person can reasonably be expected to safely transfer to an Exclusive
Provider.
3.
Such expenses are for care, treatment, services, or supplies
that are not rendered by any Exclusive Provider.
4.
Such expenses are incurred while traveling outside of the Preferred
Provider area (50 miles or more from the nearest Preferred Provider).
CATEGORY 3:
This category applies
to such Covered Expenses made by all other Non-EPO Providers.
If the Covered
Person elects to use a Non-Exclusive Provider, the Coinsurance payable
by the Covered Person shall not
apply to the Out-of-Pocket Expense Limit.
Out-of-Pocket
Expense Limit per Calendar Year:
| |
Individual
|
$ 1,500
|
| |
Family (Aggregate)
|
3,000
|
Refer to the
section entitled Medical Expense Benefit, Out-of-Pocket
Expense Limit for a listing of charges not applicable to
the Out-of-Pocket Expense Limit.
The Plan pays the
percentage listed on the following pages for Covered Expenses incurred
by a Covered Person during a Calendar Year after the Individual or Family
Deductible has been satisfied and until the Individual or Family Out-of-Pocket
Expense Limit has been reached. Thereafter, the Plan pays 100% of incurred
Covered Expenses for the remainder of the Calendar Year or until the
Maximum Benefit has been reached. Refer to the section entitled Medical
Expense Benefit, Out-of-Pocket Expense Limit for a listing of
charges not applicable to the 100% Coinsurance.
PLAN C
Benefit Description
|
EPO Provider Category
1
|
(see Page 7) Category
2
|
Non-EPO Provider Category
3
|
|
INPATIENT HOSPITAL*
|
100% Ded. Waived*
|
80%
|
Network only**
|
| |
* Benefits for Inpatient
Hospital Expenses will be subject to a separate and additional
$300 Deductible and 80% Coinsurance per unapproved admission.
|
| |
** Emergency admissions
to Non-Network providers will be covered at the EPO Benefit level
provided Covered Person is transferred to a Network provider as
early as possible. See Plan Document for details.
|
| |
|
|
|
|
OUTPATIENT SURGERY*
|
100%*
|
80%
|
NETWORK ONLY
|
| |
* Benefits for Outpatient
Surgery expenses will be subject to a separate and additional
$300 Deductible and 80-20% Coinsurance payment per unapproved
surgical procedure.
|
| |
|
|
|
|
ER SERVICES *
|
100% after $100 Co-pay
|
100% after $100 Co-pay
|
100% after $100 Co-Pay
|
| |
* The $100 Co-payment
is waived if Covered Person is admitted to the Hospital; coverage
reverts to Hospital Inpatient as noted above.
|
| |
|
|
|
|
URGENT CARE
|
100% subj. to $15 Co-pay
|
80% subj. to $15 Co-pay
|
60% subj. to $15 Co-pay
|
| |
|
|
|
|
SUPPLEMENTAL ACCIDENT
|
100% Ded. Waived up to $500.*
|
100% Ded. Waived up to $500.*
|
100% Ded. Waived up to $500.**
|
| |
* Limitation: Maximum
Benefit $500 per accident; coverage then reverts to Plan Benefits.
|
| |
|
|
|
|
PRE-ADMISSION TESTING
|
100%
|
80%
|
60%
|
| |
|
|
|
|
PHYSICIANS’ SERVICES
|
|
|
|
|
|
N/A
|
100% after $15 co-pay
|
60%
|
| |
|
|
|
|
|
80%
|
80%
|
80%
|
| |
Assistant Surgeon’s Covered
Expenses not to exceed 20% of the primary Physician’s Covered
Expenses.
|
| |
|
|
|
|
SECOND SURGICAL OPINION
|
|
|
|
|
|
N/A
|
100% Ded. Waived
|
60%
|
| |
|
|
|
|
|
N/A
|
100% Ded. Waived
|
60%
|
| |
|
|
|
|
OUTPATIENT DIAGNOSTIC
X-RAY AND LABORATORY*
|
100%*
|
100%*
|
60%*
|
| |
*Services ordered by an
EPO Physician and rendered as part of the EPO Physician office
visit shall be considered part of the EPO Physician office visit
Co-payment, whether or not the services are performed on the same
day as the office visit. Excluded from this provision is lab
work ordered for review and maintenance of a medical condition,
such as monthly visits to a lab for blood work. See “All Other
Outpatient Diagnostic X-rays and Laboratory” for benefit.
|
| |
|
|
|
|
ALL OTHER OUTPATIENT DIAGNOSTIC
X-RAYS AND LABORATORY
|
80%
|
80%
|
60%
|
| |
|
|
|
|
EXTENDED CARE FACILITY
|
N/A
|
80%
|
60%
|
| |
Limitation: Up to 30
days for treatment and Confinement per Calendar Year.
|
| |
|
|
|
|
HOME HEALTH CARE
|
N/A
|
80%
|
60%
|
| |
|
|
|
|
HOSPICE CARE
|
N/A
|
80%
|
60%
|
| |
Limitation: Maximum Benefit
per family unit for bereavement counseling is $200.
|
| |
|
|
|
|
DURABLE MEDICAL EQUIPMENT
|
N/A
|
80%
|
60%
|
| |
Limitation: Maximum Benefit
per Calendar Year not to exceed 100 days rental; Maximum Benefit
per Calendar Year for rental of Apnea Monitor (except if used
for infants), T.E.N.S. Unit or equipment designed to assist bones
to knit faster is limited to $200 each.
|
| |
|
|
|
|
PREVENTIVE CARE
|
N/A
|
100% to $300* Co-Pay and Ded.
Waived
|
Denied
|
| |
*Limitation: Up to $300
per Calendar Year benefit.
|
| |
|
|
|
|
MENTAL AND
NERVOUS DISORDERS*
|
100%*
|
80%*
|
60%*
|
| |
*Subject to a maximum
of 30 days per calendar year Inpatient services.
*Outpatient services subject
to $15 co-pay and maximum 25 visits per calendar year.
|
| |
|
|
|
|
CHEMICAL DEPENDENCY
|
|
|
|
|
Inpatient Services
|
100%*
|
80%*
|
60%*
|
| |
*Limitation: $10,000
per Covered Person per Calendar Year for Inpatient and Outpatient
Hospital
|
| |
|
|
|
|
Outpatient Services
|
N/A
|
50%*
|
50%*
|
| |
*Limitation: $2,000 per
Covered Person per Calendar Year (included in the Inpatient and/or
Outpatient limit of $10,000).
|
| |
|
|
|
|
PHYSICAL THERAPY
|
N/A
|
80%
|
60%
|
| |
|
|
|
|
SPEECH THERAPY
|
N/A
|
80%
|
60%
|
| |
|
|
|
|
CHIROPRACTIC CARE
|
N/A
|
100%*
|
N/A
|
| |
*Maximum Benefit: $25
per treatment; Maximum of 26 treatments per Calendar Year.
|
| |
|
|
|
|
AMBULANCE
|
N/A
|
80%
|
N/A
|
| |
|
|
|
|
BIRTHING CENTER
|
N/A
|
100%
|
N/A
|
| |
|
|
|
|
ALL OTHER COVERED EXPENSES
|
N/A
|
80%
|
80%
|
| |
|
|
|
|
PRESCRIPTION DRUGS
|
N/A*
|
N/A*
|
N/A*
|
| |
100% after Prescription
Drug Co-pay; $5 generic/$15 brand name. Generic will be dispensed
unless specified “Dispense as Written.” Maintenance drugs will
be dispensed through a mail order program.
|
|
|
|
|
|
Co-pay
Information
Click on the Co-pay
type to get more detailed information per the plan summary.
Return
to the top of this page.